Request for Medical Records Transfer

9/196 Parfrey Road

ROCHEDALE SOUTH QLD 4123

ABN: 12060 865 223

Ph: (07) 3341 2002 Fax: (07) 3341 3274

Email: manager@parfreymedical.com.au

Dr Vu Pham

Dr Champa Wickramasinghe

Date
MM slash DD slash YYYY
To:
Dear Doctor
Name:
DOB:
Name:
DOB:
Name:
DOB:
The above-mentioned patient/s are now attending this practice. Would you kindly forward their clinical records or an accurate health summary, with relevant correspondence and results, to assist in the future management of this patient/s. These records can be forwarded preferably by Medical Objects, otherwise by fax. The patients signed authority appears below. Yours sincerely
Dr
I ,
Request that my health summary/patient record be forwarded to Parfrey Place Medical Centre.
CAPTCHA